October 2017

Testing the Triage Team –

The New Brunswick Experience

February 16-19, 2016, the Provincial Emergency Blood Management Committee (PEBMC), Canadian Blood Services (CBS) and the Regional Health Authorities in New Brunswick participated in a simulation exercise to test the process in a Red Phase blood shortage. Previous exercises, both announced and unannounced, were focused on laboratory preparedness. The 2016 exercise was developed to highlight the importance of the triage team and the need for the participation of physicians, nurses and other health care professionals in managing a true shortage.

While there was advance notice, the actual date of the exercise was unknown to the Regional Health Authorities (RHAs). The Transfusion Medicine labs were notified by Fax and telephone call and then 2 sealed envelopes containing 10 scenarios were delivered with the CBS order that morning. We were provided with a Red phase inventory of red blood cells (RBCs) which were available to be allocated to our 10 patients.

The cases presented ranged from request for RBCs for chronically anaemic patient to motor vehicle crash and ruptured aortic aneurysm.

The triage team convened and reviewed 5 cases each day, using the guidelines in the National Emergency Blood Management Committee (NEBMC) Emergency framework for rationing of blood for massively bleeding patients during a red phase of a blood shortage – Synopsis for Triage Team to assist with allocation of red cells. The cases were reviewed one at a time and as a decision was reached, the inventory was reduced prior to review of the next case.

This exercise was invaluable in helping the members of our newly formed Triage team understand their roles and responsibilities.

It brought home the reality that in a red phase shortage, there would be patients who would be denied transfusion and that those patients may not survive.

It was very helpful in helping all of the members of the triage team in clarifying their roles. (Example Social workers, spiritual care, palliative care)

It highlighted the physicians who were missing from our team (surgeons), liaison with ambulance services.

The RHAs need to develop consistent messaging for patients affected by the shortage.

Even though it was a paper exercise, it was a very emotional experience and reinforced the reality that in a severe blood shortage, we would be unable to treat our patients in the manner to which we are accustomed.

Documentation of decision making is of crucial importance. A designated scribe is essential.

Use of Irradiated Blood Components

Irradiated cellular blood components (red blood cells [RBCs], platelets, and granulocytes) are used for transfusion recipients at risk of transfusion-associated graft versus host disease (TA-GvHD). Immunocompetent T lymphocytes in the transfused component can attack the immune system of immunocompromised recipients, causing TA-GvHD, which is almost invariably fatal. Immunocompetent recipients can also develop TA-GvHD if transfused with HLA-similar (haploidentical or matched) components, in which case the donor blood is not recognised as foreign by the recipient, but the recipient tissues are recognised as foreign by viable donor T lymphocytes. Irradiated components are provided by Canadian Blood Services (CBS) for hospitals which do not have an on-site irradiator. Although leukoreduction appears to reduce the risk of TA-GvHD, it is not considered sufficient.

Bloody Easy 4, and Chapter 15 of the on-line version of the CBS Clinical Guide to Transfusion both discuss this topic, and provide lists of the type of recipients who must receive irradiated blood components1, 2. The National Advisory Committee on Blood and Blood Products (NAC) will also be publishing recommendations on the use of irradiated blood components. The draft document is available on the internet3, but watch the official NAC website for the final recommendations, due to be posted in the fall of 20174. Patients requiring irradiated components should wear an ID bracelet or carry a wallet card stating this fact.

Irradiated RBC components show more hemolysis than non-irradiated red cells, and contain higher concentrations of potassium. CBS and many hospitals have adopted the Council of Europe Guidelines for the use of irradiated components, which state that red cells may be irradiated up to 28 days after collection. They must then be transfused as soon as possible, but no later than 14 days after irradiation and, in any case, no later than 28 days after collection. The guideline is more strict for neonates5. Because of the lower quality of the component, irradiated RBCs should not be given to patients who do not require them.

What do you do if a transfusion is urgent, there is no on-site irradiator, and the delay for delivery of irradiated components is unacceptable to the ordering physician? A recent systematic review of TA-GvHD found that the storage duration of the implicated component was less than or equal to 10 days in 94% of 348 cases6. Other studies have shown that the oldest component implicated in TA-GvHD was less than or equal to 14 days old. Therefore, the use of non-irradiated components greater than 14 days old may be an alternative when irradiated blood is not available and the need for transfusion is urgent.

Situations Requiring Irradiated Blood Components1,2,3

intrauterine transfusion (IUT)

neonatal top-up transfusion or exchange transfusion if previous IUT

neonatal exchange transfusion unless transfusion would be delayed

neonatal top-up transfusion in neonate less than 4 months of age or less than 1200g